There is increasing evidence that ambient air pollution is associated with coronary heart disease morbidity and mortality. This research has focused on the general public and less so on possible sensitive subgroups even though these may have even greater susceptibility to adverse effects of ambient air pollution. With highly prevalent traditional as well as nontraditional risk factors, renal transplant recipients may potentially be a sensitive subgroup. The purpose of this study was to evaluate the possible effect of between long-term exposure to air pollution on the risk of CHD mortality among renal transplant recipients. This cohort study includes 32,239 adult, renal transplant recipients, transplanted between 1997-2002, identified through the US Renal Data System (USRDS) and living in the continental U.S.A. Monthly concentrations of O3, NO2, SO2, PM10 and PM2.5 were calculated from ambient monitoring data and interpolated to ZfP-code centroids according to the residence of the renal transplant subjects. Time dependent Cox Proportional Hazard models were used to estimate the effect of ambient air pollutants on risk of CHD mortality, while adjusting for potential confounders. For each increase of 10 ppb increase in O3 the risk of fatal CHD increased by 52% (Relative Risk (RR) = 1.52, 95% Confidence Interval (Cl): 1.34-1.73) in the single pollutant model and by 54% (RR = 1.54, 95% Cl: 1.36-1.76) in the two-pollutant model adjusted for PM10. The pollutant with the strongest association with fatal CHD was PM2.5 adjusted for O3 (RR = 1.89, 95%CI, 1.22-2.91). A small and significant association was found for SO2, but no association was found for either NO2 or PM10. In both the age- and multivariable adjusted models, there was a significant association between risk of fatal CHD and O3 for both males and females, with females exhibiting the strongest association with each 10 ppb increase (RRmales = 1.43, 95%CI: 1.26-1.63 and RRfemales = 1.67, 95%CI: 1.39-2.00). Ambient levels of fine particulate matter and ozone are associated with risk of fatal CHD among renal transplant recipients. These findings could have potential implications for policies and regulations of air pollution. Additionally, these results may be relevant in developing individual CVD risk reduction strategies for renal transplant recipients to ultimately improve long-term survival.

LLU Discipline



Epidemiology and Biostatistics


School of Public Health

First Advisor

Synnove F. Knutsen

Second Advisor

W. Lawrence Beeson

Third Advisor

Mark Ghamsary

Fourth Advisor

Sam Soret

Degree Name

Doctor of Public Health (DrPH)

Degree Level


Year Degree Awarded


Date (Title Page)




Library of Congress/MESH Subject Headings

Kidneys -- Transplantation; Air -- Pollution -- Health aspects; Air -- Pollution -- Measurement -- Statistical methods; Spatial analysis (Statistics); Kidney Transplantation -- statistics and numerical data; Kidney Transplantation -- mortality; Coronary Disease -- complications; Coronary Disease -- epidemiology -- United States; Outcome and Process Assessment (Health Care); Environment and Public Health; Risk Factors; Air Pollution -- adverse effects; Proportional Hazards Models; Regression Analysis.



Page Count

xiii; 160

Digital Format


Digital Publisher

Loma Linda University Libraries

Usage Rights

This title appears here courtesy of the author, who has granted Loma Linda University a limited, non-exclusive right to make this publication available to the public. The author retains all other copyrights.


Loma Linda University Electronic Theses and Dissertations

Collection Website



Loma Linda University. Del E. Webb Memorial Library. University Archives